Substance Use Disorders

Question 1

What are Canada’s drinking guidelines?

Answer 1

Women: 10 drinks per week or 2 drinks per day
Men: 15 drinks per week or 3 drinks per day

At 3 to 6 standard drinks per week - Your risk of developing several different types of cancer, including breast and colon cancer, increases.
At 7 or more standard drinks per week - Your risk of heart disease or stroke increases.

Question 2

What are some complications or alcohol use disorder?

Answer 2

• Poor nutrition (thiamine deficiency, low potassium, low magnesium, low phosphorus)
• Liver disease
• Bleeding diathesis (increased INR, impaired platelet function/thrombocytopenia)
• Tremor, ataxia, seizures, Wernicke encephalopathy
• Autonomic dysfunction (hypertension, dehydration, pyrexia)
• Neuropathy
• Trauma
• Increased risk of certain cancers (mouth, throat, liver, colon, breast)
• Infections (aspiration pneumonia, cellulitis)
• Concurrent psychiatric disorders (depression, anxiety)
• Psychosis (hallucinations, delusions)
• Insomnia and sleep apnea

Question 3

What is Wernicke encephalopathy

Answer 3

a degenerative brain disorder caused by the lack of Vitamin B1. It may result from alcohol abuse.
characterized by three main clinical symptoms: confusion, the inability to coordinate voluntary movement (ataxia) and eye (ocular) abnormalities.

Korsakoff syndrome (WKS can also result from lack of vit B1

Question 4

What is a screening tool that can be used to detect those at risk for alcohol related disorders?

Answer 4

CAGE
1. Have you ever felt you ought to Cut down on your drinking or drug use?
2. Have people Annoyed you by criticizing your drinking or drug use?
3. Have you felt bad or Guilty about your drinking or drug use?
4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (Eye-opener)?

*A total score of two or greater is considered clinically significant.

Question 5

What is a screening tool to assess for alcohol withdrawal?

Answer 5

CIWA - a score above 20, hallucinations or other concerning symptoms; or a score of 10 or higher after 4 doses of diazepam at 80 mg requires ER withdrawal management

Question 6

What are the steps for motivational interviewing?

Answer 6

Need to assess readiness for change:
1) Precontemplation (encourage pt to openly discuss their alcohol use, discuss consequences of it but avoid judgement.
2) Contemplation- encourage list of pros, cons of alcohol, provide positive reinforcement of change talk.
3) Preparation- work on practical elements of planning the quit/reduction attempt. Discuss tx options
4) Action- monitor progress, positive reinforcement
5) Maintenance- continue to provide positive reinforcement, work on relapse-prevention skills, self-management, build community based network of support
6) Relapse- normalize relapse as part of the disease, frame relapse as learning opportunity and not as failure, excessive guilt can lead to shame and worsen relapse

Question 7

How is alcohol use disorder diagnosed?

Answer 7

Mild: Presence of 2–3 symptoms
Moderate: Presence of 4−5 symptoms
Severe: Presence of 6 or more symptoms

A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12-month period:
1. Alcohol is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol or recover from its effects.
4. Craving, or a strong desire or urge to use alcohol.
5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school or home.
6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
7. Important social, occupational or recreational activities are given up or reduced because of alcohol use.
8. Recurrent alcohol use in situations in which it is physically hazardous.
9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
10. Tolerance, as defined by either of the following:
- A need for markedly increased amounts of alcohol to achieve intoxication or desired effect
- A markedly diminished effect with continued use of the same amount of alcohol
11. Withdrawal, as manifested by either of the following:
- The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal)
- Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms

Question 8

Non pharm for AUD?

Answer 8

Motivational interviewing combined with CBT is associated with a significant increase in abstinence rates. This combination is effective in patients with comorbid depression and anxiety, which is a common presentation in alcohol use disorder.

Question 9

What is the treatment of choice for those wishing to reduce alcohol but not abstain?

Answer 9

Naltrexone (Opioid Antagonist) 50mg PO daily
* Patient must be opioid-free for ≥7 days prior to initiation of treatment.

Question 10

What is the treatment of choice for those wishing to abstain from alcohol?

Answer 10

Campral - Acamprosate (Glutamate Antagonist) 666 mg PO TID can use 333mg tid for low wt
*Start treatment after ≥4 days of alcohol abstinence.
*Treatment of choice for patients on opioid therapy.

Question 11

What is a supplement given in AUD to prevent Wernicke-Korsakoff syndrome?

Answer 11

Thiamine 200mg daily

Question 12

When would you expect to see symptoms of alcohol withdrawal start?

Answer 12

Symptoms of AW may develop 6-24 hrs after the last drink and may vary from mild autonomic hyperactivity such as agitation, tremors, irritability, anxiety, depression, hyperreflexia, confusion, hypertension, tachycardia, fever, diaphoresis, nausea to severe forms characterized by hallucinations, seizures, delirium tremens (DTs) and coma.
- Mild-moderate AW is often times self-managed and resolves within 2-7 days after the last drink

Question 13

What are the options for alcohol withdrawal treatments?

Answer 13

Benzodiazepines – mainstay of AW pharmacological treatment: diazepam, lorazepam (preferred in elderly &/or hepatic dysfunction), midazolam
Barbiturates – phenobarbital PO/IV (high doses - ICU monitoring may be required)
Hypnotics – propofol (only in ICU)

• Treat according to symptom severity using (CIWA-Ar).
• If CIWA-Ar score increases and/or does not improve after 4 doses of bentos, refer to emergency department.

Question 14

What needs to be included in a benzo prescription?

Answer 14

When writing an Rx for a Benzodiazepine (or any controlled substance) you need to include:
- Patient DOB (Address is also helpful)
- Patient OHIP #
- Write out the number of tablets given; write “three” instead of “3”
*Repeats are not allowed to be written on controlled substances

Question 15

What are options for non-opioid pharmacotherapy?

Answer 15

• Acetaminophen and / or nonsteroidal anti-inflammatory drugs (NSAIDs) are effective as first-line analgesia
• Anticonvulsants (gabapentin and pregabalin)
• Antidepressants (amitriptyline, nortriptyline, and duloxetine)
• Psychological interventions: CBT, guided imagery, other relaxation techniques
• Self-management interventions (heat, ice massage, stretching and rest)

Question 16

What is involved with an opioid contract?

Answer 16

a) agree to not seek out other prescribing providers;
b) agree to urine drug screening at each visit;
c) educate on signs and symptoms of overdose, i.e. consider giving naloxone rescue kit;
d) use only one pharmacy and instruct the pharmacy to dispense narcotics daily, twice weekly or weekly;
e) allow no refills

Question 17

What constitutes an opioid use disorder?

Answer 17

a repeated occurrence within a 12-month period of 2 or more of 11 problems, including withdrawal, giving up important life events in order to use opioids, and excessive time spent using opioids. A cluster of 6 or more items indicates a severe condition

Opioid use is often a chronic, relapsing condition associated with an increased mortality and death; sustained long-term remission is possible with an appropriate treatment and patient and family OUD education

Question 18

What is the 1st line treatment for OUD?

Answer 18

Buprenorphine-Naloxone (4:1 ratio) “Suboxone”
1st dose: 2–4 mg tablet (buprenorphine) - if still in withdrawal later in the day, may repeat dose 1 time only; titrate to effect. Increase by 2–4 mg daily to a maximum of 16 mg over 3 days. Goal is to relieve withdrawal symptoms for up to 24 hours.
To discontinue: reduce dose by maximum of 2 mg every 1–3 days (in-patients) or 2 mg/week (out-patients).
- Long-term maintenance: 8–24 mg (buprenorphine) daily SL.
*Place tablet(s) under tongue or in cheek; allow to dissolve over 2-10 minutes. Do not chew or swallow whole, & do not eat, drink, or smoke until tablet fully dissolved!
- In-office induction is preferred if patient is not already in withdrawal.
- Ideal home initiation candidates are experienced with buprenorphine-naloxone, reliable, able to follow up (in office or phone), stable/supported in their home environment, able to safely store it, unable to attend office, & able to call the physician.
- A hybrid initiation approach utilizes directly observed dosing at the pharmacy until patient stable

Question 19

What scales are used to assess opioid withdrawal?

Answer 19

COWS (Clinical Opiate Withdrawal Scale) and SOWS (Subjective Opiate Withdrawal Scale) are scales to assess opiate withdrawal and support buprenorphine-naloxone initiation.
* Generally requires 6-12 hours since last short-acting opioid (e.g., heroin, morphine, hydrocodone), 18 hours if SR opioid (e.g., Contins), & 24-36 (sometimes 72) hours after methadone

Question 20

What are the CI to Suboxone?

Answer 20

respiratory insufficiency, severe hepatic impairment, acute alcoholism, convulsive disorders, MAOI use within 14 days, GI obstruction

Question 21

What are the disadvantages of methadone for OUD?

Answer 21

Greater risk of overdose during initiation; longer time to reach maintenance dose (>35 days); less tolerable adverse effects; more drug interactions; greater risk of abuse/misuse compared with buprenorphine-naloxone and thus more likely to require daily witnessed ingestion.

Question 22

What treatment for OUD is preferred in pregnancy?

Answer 22

Buprenorphine monotherapy
- Methadone was previously considered the standard of care for pregnant patients with OUD: may need BID dosing in 2nd and 3rd trimesters d/t increased metabolism
- Compared to methadone, buprenorphine has less severe NOWS (Neonatal Opioid Withdrawal Symptoms) & potentially lower risk of preterm labour, larger head circumference, greater birthweight.

Question 23

how often should you see your patients on OUD therapy?

Answer 23

• follow-up appointment weekly – contact the referral source (i.e., drug rehabilitation program) before the next follow-up visit to check on the patient’s progress. At the follow-up visits, always question the patient regarding compliance.
• Order urine drug screening with every office visit while in outpatient treatment and throughout the year following treatment
• Once a positive change is seen, the patient may be seen monthly. Discuss changes the patient has made, past relapses, circumstances under which they occurred, and any special concerns.
• Refer patients with OUD to a community mental health centre that has an outpatient drug rehabilitation program or to a specialist in the community that deals frequently with OUD.

Question 24

How are opioids tapered?

Answer 24

To taper the opioid that is being used by the patient, lower the dose of the opioid by 5-10% every 2-4 weeks and regularly monitor!

Question 25

What is the treatment of schizophrenia?

Answer 25

FGAs (first generation antipsychotics) & SGAs (second generation antipsychotics) have similar efficacy, tailor treatment to the specific phase of the disorder and to the patient’s signs and symptoms

Aripiprazole, paliperidone palmitate and risperidone are examples of long acting antipsychotic injections-these should be offered in all phases of illness, including first episode after establishing tolerability with oral formulations. Long-acting injections may improve rates of remission and decrease the risk of hospitalization and relapse

Question 26

What are the side effects associated with 1st generation antipsychotics?

Answer 26

Low potency agents have greater rates of sedation, CV effects, anticholinergic effects and wt gain, low seizure threshold, photosensitivity
High-potency agents have greater rates of extrapyramidal side effects (EPS, neuroleptic malignant syndrome) and elevated prolactin levels
All: liver function abnormalities

Question 27

How long should patient with schizophrenia remain on treatment for?

Answer 27

Continue maintenance pharmacotherapy for at least 1–2 years for first-episode patients who achieve symptom remission and functional recovery. Longer treatment (2–5 years) may be required for individuals with a long duration of untreated psychosis, more severe illness, slower response, substance abuse, and history of suicidal or aggressive behaviour.
For patients with a history of 2 or more episodes, continue maintenance pharmacotherapy until the patient has been stable and relapse-free for at least 5 years. Many require antipsychotics treatment indefinitely.
When discontinuing medication, gradually reduce the dose by ≤20% every 2–4 weeks. Reduce over a period of 6–12 months for first-episode patients and 6–24 months if patients have experienced 2 or more episodes. Monitor closely; if patients experience early signs of relapse, restabilize them on the previously effective dose of antipsychotic as quickly as possible.

Question 28

Should patients with schizophrenia be on more than 1 treatment?

Answer 28

Combination therapy with more than 1 antipsychotic medication (antipsychotic polypharmacy) is not supported by evidence except for: cross-titration when switching to a different antipsychotics adjunctive treatment for partial responders to clozapine